of the ethical dilemma that is present, each party contributes to a conversation about how to define and frame the problem. All of the questions posed by the virtue ethics model related to stakeholders and feelings are relevant here. What extends the virtue ethics model is the inclusion of the clients in defining the problem as well as understanding the cultural values that the family practitioner brings to the process. From a postmodern perspective, the cultural selves of family practitioners are not simply acknowledged and managed but are embraced and brought into conversations with the clients. In this way, the emphasis is on situating the counselor’s selves as cultural beings within the decision-making process, highlighting, not hiding, such influences. The family practitioner trusts the family to handle the very human, ethical struggle in which the practitioner and all other parties are engaged.3 Developing solutions. This step of the participatory ethics model is very similar to Steps 5 and 6 of the virtue ethics model. Again, the defining element of the participatory model is valuing clients’ conceptualizations of solutions and their reaction to each possibility. Consultation is integral to the process of developing solutions and may involve inviting still other voices into collaborative conversations with clients.Even though we are presenting the participatory ethics model in linear steps, in this model, like most approaches to family systems, the steps are recursive—with each step influencing and being influenced by the others. Furthermore, it is not uncommon for each additional step to require adjustments and reconsiderations in earlier steps. All of this is especially true when consultation is being integrated into the process. Engaging in consultation may require circling back to previous conversations, and consultation may be integrated throughout the rest of the process. In participatory ethics, no single step can be a one-time occurrence in the process of ethical decision-making.
4 Choosing a solution. Just as the virtue ethics model values self-reflection at both the rational and emotional levels, participatory ethics values conversations with clients about their processes and reactions, rationally and emotionally, to possible solutions. Respect for self-agency is central to the dialogue, and the goal is to select a solution that all parties, including the family practitioner, can support.
5 Reviewing the process. This step starts with the family practitioner openly reflecting on all aspects of the ethical decision-making process in which the counselor is engaged:Would the family practitioner want to be treated this way?How are the values and personal characteristics of the family practitioner influencing the choices that have been made?What has been the effect of the family practitioner’s power in these ethical conversations?Have the clients’ perspectives been taken into account? (Rave & Larsen, 1995).Opening oneself to deliberate reflection may serve to check the credibility and trustworthiness of the constructed solution. It also models for clients the importance of self-reflection in this participatory process.
6 Implementing and evaluating the decision. Participatory ethics recognizes that ethical dilemmas force everyone into a state of vulnerability and sometimes anxiety (Coale, 1998). It is a model in which all parties participate in both the decision-making and the consequences of the decisions made. The process cannot end with the implementation of a decision: Evaluation and regular reevaluation are essential:Does the outcome continue to feel right?How has the decision affected the therapeutic process?Is the solution we chose the best we can do?
7 Continuing to reflect. The last step in the participatory ethics model returns the family practitioner to self-reflection and a consideration of the ethical decision-making process in a removed or disengaged space:What did I learn from the process about myself and about the participatory process?How might this experience affect me in the future?How, if at all, have I changed as a result of my participation in the process?The practitioner must not only examine the outcome for the client but also reflect on the decision’s impact in relation to themselves. Each and every decision made extends into the future, well beyond the current clients’ situation. Valuing personal and professional experiences of the process through continued reflection facilitates greater awareness and learning for the family practitioner and enhances the ethical process with future clients.
We have presented only three models of ethical decision-making here. What reactions do you have to each of them? What feelings surface? Your thoughts and feelings speak to the kind of person you want to be as a family practitioner.
Common Ethical Dilemmas in Couples and Family Practice
We now shift to a discussion of some of the most commonly encountered or constructed ethical dilemmas when working with couples and family members. Whole texts have been written addressing ethics in family practice (Golden, 2004; Herlihy & Corey, 2015; IAMFC, 2017; Murphy & Hecker, 2017; Wilcoxon et al., 2013; Woody & Woody, 2001): The most common dilemmas that surface are related to confidentiality, multiple clients, informed consent, and gender and multicultural issues. We now delineate some of the issues that family practitioners have faced in these four areas. This is not a comprehensive list, and there are no easy answers to propose. We touch on these issues so that you will know that you are not alone when you are confronted with similar ethical problems. Reflect on Sidebar 4.1.
Sidebar 4.1 • A Learning Challenge
Family practitioners actually have very little time to reflect on their place in ethical decision-making processes. Managed care has not found a way to reimburse self-awareness. Here is a challenge for you: Take a practicing family counselor to lunch and ask some of the questions we have asked you to consider. When finished, ask your companion what it was like to spend 30–60 minutes in conversation with you about such topics. Now, we are willing to bet that if you succeed in being genuinely curious during your questioning, the majority of family practitioners will say something like, “You know, I don’t get to do this very often. This was great! I wish I could find more time to do this.” Reflective conversations like these engage professionals in self-care, help to prevent burnout, and encourage ethical practices
Confidentiality
Trust in any therapeutic relationship is intimately tied to the guarantee of confidentiality. The ability to speak openly and with emotional honesty is supported by a trusting relationship that ensures a respect for privacy. This right to privacy in psychotherapy is recognized in all 50 states and by the federal government in HIPAA standards and Supreme Court decisions. But what degree of privacy can a family counselor or therapist truly uphold? Maintaining confidentiality can be an enormous responsibility for a practitioner working with just one person. When a counselor is working with multiple people in one room, the challenges to maintaining confidentiality increase exponentially. It is in the subtexts of confidentiality and family practice that ethical issues become extremely difficult, especially those of conceptualizing the client served, providing informed consent, and handling relational matters in an individual context.
Conceptualizing the Client
If your practice consists solely of individual clients, the definition of client is clear: It is the person sitting across from you in a counseling or therapy session. The more systemically oriented counselors, however, embrace the family as a whole as the client—with many, like Whitaker, insisting that all members of the family be present before therapy begins. The first practitioners of Bowen family therapy, structural family therapy, and the various strategic therapies emphasized family dynamics in which individuals were little more than parts of an interaction or actors in a systemic drama. In the past decade, there has been a concerted effort to reinstate the individual into family systems theories, with postmodern models tending to conceptualize families and clients as those individuals who are in conversation about any given problem. In these later models, those in conversation about a problem determine who needs to be involved in family sessions.3 What happens to confidentiality in these shifting conceptualizations of family is at the heart of one whole set of ethical
